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110 Cecil Ln Lot 1 ``- ',>'.� r z..;'.•1i.._,y9"'``ts., -�. V+ '3t'?1' 0.f✓r: Z i t AUTHORIZATION NO:. DAVIE OUNTY HEALTH DEPARTMENT .�IZA Environmental Health Section PROPERTY INFORMATION. Permittee'. + P.O.Box 848 �. A Name: Mocksville,`NC 27028 Subdivision Name: .Phone# 336-751-8760 Directions to property: Section: Lot: AUTHORIZATION FOR WASTEWATER. Tax Office PINAr - _'4 - SYSTEM CONSTRUCTION Road Name' Zip: 0Qaa **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building-Permits.This Fonn/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits.` (In compliance with Article 1 I of G.S.Chapter.I30A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED „w! -.. •r -'”^�" ^!+`,1' r x ..rY ._ .'a^., .�- '1'-.. .,'I%,' 'i� tea. T* 117 6 DAVIE OUNTY HEALTH DEPARTMENT ; D IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION " Permittee' _ • - . -.; . Name.. ; Subdivision Name: _ ,T Directions to property: , t°% '�,'{,!I "'/ % ' 1 Section Lot: IMPROVEMENT , 1 ' ( Y PERMIT Tax Office PIN: r if t' ,} Road Name- 3 Zip: *-*NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a'se'ptic tank system or any wastewater system.An., AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained fturn this Department prior to the construction/installation of a system or the issuance of a building pen-nit. (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) r ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONMENTAL HEA H SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM: RESIDENTIAL SPECIFICATION:BUILDING TYPE_ _ #BEDROOMS #BATHS,-F, #OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:.Yes or No LOT SIZE,!<' L TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) 6ba NEW SITE !/ REPAIR SITE ` �i oo SYSTEM SPECIFICATIONS:-TANK SIZE,,.{O OGAL.' PUMP TANK GAL. TRENCH WIDTH ROCK D LINEAR FT., OTHER ��f !Q , ., •_c,/_� �T . REQUIRED SITE MODIFICATIONS/CONDMONS: IMPROVEMENT PERMIT LAYOUT yoo jet p 0 l: �.• �° Oda "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM' BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: WX d�j uIt, 'p0 X09 lit) AUTHORIZATION NO., 1*7 e'V OPERATION PERMIT BY: DATE: **THE ISSUANCE OF.THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF,TIME. DCHD 05M(Revised) , >,,;; APPUCATION FOR SITE EVAMATIOWIMPROVEMEM PERMIF do ATC V' r y� Davie County Health Department EnvironmentalHeaftSeWOV P.O. Box 848/210 Hospital Street Nov 4 19^R Mocksville, NC 27028 (336)751-8760 - 1R 17T ***ZHPCRTANT*** TRIS APPLICATION CANNOT B8 PIW SSLED UNLESS ALL THE' QLJIREI) INFORMATION IS PROVIDED. Refer to the INr=QTION BULLETIN for instructions. 1. Kamm to be Billed Contact person ��Q fYrIL�2 !!ailing Address altI kNir a 10 Home Phonegq if 7O�(03 t� city/state/zipn/_ /, ~�f P�C_ 7� D,�rJ Business Phone 2. flame on Pezmit/ASC it Different than Above Hailing Address C�ity�/state/zip 3. ]Application For: U Site Evaluation B'Improvement Permit/ATC 0 Both e. system to service: O'House 0 Mobile Home 0 Business 0 Industry 0 Other s. If Residence: ; People ; Bedrooms ; Bathrooms fl'Dishxasher O Garbage Disposal WRashing Machine 0 Basesent/Pivsbing Basement/Ho Plumbing S. If Business/Industry/other: specify type ; People ; sinks ; Commodes ; shovers ; Urinals ; Rater Coolers IF FOODSERVICE: Seats Estimated water Usage (gallons per day) 7. Type of water supply: 0 County/City ['well 0 Community 8. Do you anticipate additions or expansions of the facility this system is Intended to serve! 0 Yes U yes,what type' ***IMPORTANT'**CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 5, n� ! �'�F S WRITE DIRECTIONS(from MockrAlle)to PROPERTY: Tax Office PIN: 5�.� �8- ��a�!_�oa P. a1 /1� >� i�G Aa /T on Property Address: Road Name e City/Tip tae- d, / l_ _. �,ib n�yI`'r/ ��� �/t ZS �D/01#1 If in a Subdivision provide information,as follows: Name: Pi-n e LI t, e.c) AG res Section: Block: Lot: / Date Property Flagged: 4ZZ�Z?k This is to certify that the information provided h correct to the best of my knowledge. I understand that any permit(s) Issued hereafter are subject to suspension or revocation,if the site pians or intended use change,or If the Information submitted In this application is falsified or changed 1,also,understand that l am responsiblejor all ciarga lncurred from this application. I,bereby,give consent to the Authorized Representative of the Davie County�eaitb Department to enter upon above described property located in Davie County and owned by C F�,lis e <gys to conduct all testin procedures as necessary to determine the site suitability. DATE L SIGNATURE- 'Z THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Account No. Revised DC►ID(07/98) Invoice No. 9 ",�•� •;`4 gpµv� CHARLES R.BOGER I ,��(i • '� I 0.8.162 PG.764-766 CHARLES R. ID.B.162 PG.7 Isw I N 98•24'10'E -� 393.56 - 3 42.33.47.E 427.62 - _� lr A—crux! Onn m AMAr A�4_ _ JAMES C.F[ m AIdBEA r&009 — D.B.166 P 4001 G. o I 1 MP 1421.911olal) 25.00 N► N 6T•4T 53'E Af 366.53 F5,00 396.91 nw 5 87.47 W I a 1393.53 1.1 IoIA I I I _ E ROBERT 5KUR G. OgjACW o I rl al ANS I CANS GANS ter- �I JAMES W. 74 - I I D.B.172 1 1421.94711e1e1 53'1E I,y 67. - 1 396.91 23.00 I ' ' fe L I _ � I 0 I I w I I /IGi�A r�O1 AC06�8R_ I I 'tunes u I4ae aiw I� I RONALD 1 D.B.171 P ;. -1435 1 { } �RiBGE ROAD I I it'e/nNl : n �a 4 r fie„ ��, a'n. J•A APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE Davie County Health Department Environmental Health Section P. 0. Box 665 ' Mocksville, NC 27028 AUG — 9 1995 , a v t`"� 2/d 1. Application/Permit Requested By CS`11:9�_e- I `• Mailing Address �4�- ��`�'� r—D/ ,Al Home Phone ASV&-X ,/Y C- rW6 Business Phone 2. Name on Permit if Different thin Above # 3. Application for. A(General Evaluation ❑Sepfic'Tank Installation Permit f 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry 1 ❑ Other ❑ Unknownk n 4 ,.,. 5. If house, mobile home:Subdivision 1' : w �- �'e.� A C S Section Lot � i;-,; ❑ Basement/Plumbing No.of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No.of Bathrooms 2' ❑ Dishwasher ~i Dwelling Dimensions 3a ❑ Garbage Disposal 6. If business, industry,place of public assembly, other: Specify type No. of People Served No. of Sinks No.of Commodes No. of Urinals t,•.? No. of Lavatories No. of Water Coolers No.of Showers Water Usage Figures 7. Type of water supply: ❑ Public VPrivate ❑ Community f;1 8. Property Dimensions Sewage Disposal Contractor. 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes,what type? 'NOTE: Improvements Permits shall be valid for a period of 5 years from date Issued.-Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1,-1989. i' Directions to Property: '=. Pc/d. rJ :"` i �� e . Ce C r` I e 9 ,q ,Js bl Af CJ) "J� 6.V ,See NQWPLAc-A ' m3 ),A7e is 1 ` This is to certify that the information provided is correct tot st of my knowledge, and I understand I am responsible for all charges f incurred from this application. 4 DATE SAGNATURE CONSENT FOR SITE EVALUATION TORE.DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. ti-1. I DO NOT OWN the property. If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner: 1 hereby give consent to the authorized representative ofh�D vie Co my Health Department to enter upon above described property located in Davie County and owned by �d [S� ,� G��Q S_ to conduct all testing procedures as necessary to determine id site's suits slit for a ground absorption sewage treatment and disposal system. DATE SIGN URE DCHD'pro3i k: ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation 9'` NAME `J O cn �. DATE EVALUATED QP ADDRESS S l>`t`rn`� PROPERTY SIZE C3� PROPOSED FACIILTY O V S LOCATION OF SITE VO q V1eW C R Water Supply: On-Site Well _ Community Public Evaluation By..( t L- Auger Boring V Pit Cut FACTORS 1 2 3 4 Landscape position S Sloe z - /S 6-77 HORIZON I DEPTH Lab l� ' Texture group C Consistence 1- Structure C Mineralogy ' 1 HORIZON II DEPTH Texture group Consistence 77- Structure -Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: .S EVALUATED BY: LONG-TERM ACCEPTANCE RATEi "✓ -�OTHER(S) PRESENT: REMARKS: , ` ��� �SQ�� ► � 4- LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope _Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty :lay loam- SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-V?---y friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure 3C-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1, 2:1, Mixed Notes horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD(01-901 ■./■■■■■■■■■■■■■/■■■■■■■■■■■■■/.■■■■■■■.■■■■/.■■■■■■■■■■■■ NOON■■■ ■.■■■■■■■■■/■E■■■■EEEEEE■■■■■E■■ .■■■■.■■■■�■■■/■■EE.l�1�■■.M■■■■■■ ■■/■■■■■■■■.■■■./■■..■■■■■■ NOON■■E■■M■ NOON■■■ ■■■� NOONO■■■■■■■ ....................■......�MEMEME■■■MEMMOMMEMEi■■SMi■MEN °...°°.. ■■■■■■■■■■■■■■■■■■.■■■■■■■■.■■■■■■■■■■..■■■■■■ ■NOON■H ■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■.■■■■.■■■■■■■■■■■■■■�■■.��■�■I■■°I ■■■■■■R ■■.■■■.■■■■.■■■■■■■■■.■■■■■■■■..■■.■■■■■ NOM ■ ■O■ ■O■EM■EE ■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MEMO■.■■■E■ME■■■■■■.E■■EH■■■■■■ ■■■■■■■.■■■■.■..■■■■■■■■■■■■■■■ ■■■■■.MSM■■M■■OO■■■.■■■■OM■■M■■■ ■■■■■■■■■■■.■■■■■■■■.■■■■■■■■■■■■■.■■■■.■■■■■■■ ■ ■.■E■EE■■■■■■■ ■■■■■■.■■■..■■■.■■■■.■■■■/■.■■■■■■■■ NMON■■ /■■■■■ NONE■ MEMO.■■■ ............................................■_■■■■.EC.■■■■E■■==■■C NOON■.■N■M.EOMM■E■■■■■E■/E■■■■■ ■■■NNE■N . ...■..........■■ MEN ................................ ......■■■=E■■SON MEMOMME■E■■■■■ ■■■■■■M■■■■E■■■■■■■MMH■■■■■■■■■■■■N■■■■■MN■■M NOON ■■■■■■■■■■. ......................N■■MM■MM.M■M.....■..■■.■■■■■.■ °■.�■■.... ■■■■■■■■NO■EE■.■■■■■■■■■■■■■■■■■■■■....■■■MN■■.■ ■■N■ MENEM■I� ...........°..■...................■..........■■■ ■ M■NE■.■■■.■■Mi ■■■NMN■■■■.f1■■■■■■■MMN■■.■E■■MEM■MMS■■.■ ■EME■■■ N■ NOON IMMEMMMM SOMEONE ■■/■■■.NOON■11■■■■O■■.N■■.■/..■E�M■■ONE■■NEN■NM■E■.EM■�■■■■■■■■ ■■MEMNOON■O.[.1■■■■■.E■■■NE■■E.■■■ MEN■NMEMEME mom mom MEMEMEM ■■■�NE■E■.`■u■N■■NNM■.■.■■MM■■mom■■■■M■■■■N MEN MM■■■■■� ■■M■ ■E ■E■■■■■■ MEME.■ ■ EME■■■■I � MEN MENNEN ■■E■■■■■■■■riEE■■■N■■■■■NN.■■�■cr�����_ '�CCii Ii M■ NOON■ ■■.■M■■E■■■■■■Esq■E.■■N■Nu■M►!e�_ ■ INi ■ INN"�C'=■ME■■� om UMEMEME �MEMME[Ifi. iiaNONE ;■M■ ■ �■'iMEl�OMEN�1°[ NOON■■ NOON■C/ ■EEMMEMMOMHME/.MOM■MON[1■■■=M■MNONEM■■■ ■ MEN MEMOMEMEMMEM ■■■■■.■■.■.././..■.E�:OM.►7.E■\Gi■M■S■E "�►• ME ONE momM am 0 M0 ■■/.■■■■■■OI�ENO■■■�..\■EOM/110PPR WE ME MENEMNo EMEMMMM ■■/■NEE IEMEINEO■EMMMM�=i'■H■�I[C!■I P on MONOMERMMMMOMM WERE 0 ■■■ENE■■■■��.M�■HMNIna .M■=■M■ ■ NEON M M mom ■■■■■■MMM MMMM■■OMMEMMMA M■■=MMM■■ - __ ■M■ OEM no ■E■■■Nr�M■■�M M='==MM■■■Mi�►oma►'■■ ■Ou■ u, No u■■■■■ ■■MEMEMEMKINi■OREMEMMMMUR"PUMMEMM ■ ■ 1 - M■ESE■ ■■EEM■I/EM.I■■EE■■M�\■■■■rM.■■■MM M M� N MEMEME■ NOON■■1■■■�IE.MMMHM■��N■■■.N■EMS■ ■■ N..N■ ■■■.N■■NSI■.■ ■■CCMENUMME.MEN ■ ■ (/ H■■■■■■■S■■ E■N■■■■ Ci: MMMMMM=i:::i�. ::. _" MOM MONOMER man■■■MME■ C�■■MM■ESEN■■.■ii:�cM... 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